Provider Demographics
NPI:1023315710
Name:WILDER, VICKY LYNNE (NCC)
Entity type:Individual
Prefix:MRS
First Name:VICKY
Middle Name:LYNNE
Last Name:WILDER
Suffix:
Gender:F
Credentials:NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8913 BOULVARD OF THE GENERAL
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22553
Mailing Address - Country:US
Mailing Address - Phone:540-786-7227
Mailing Address - Fax:877-771-3419
Practice Address - Street 1:8913 BLVD OF THE GENERAL
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22553
Practice Address - Country:US
Practice Address - Phone:540-786-7227
Practice Address - Fax:877-771-3419
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA61066101YP2500X
VA466-1986225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist